Complete Report

Summary

For 98 of the 100 claims that we sampled, Norwalk Hospital (the Hospital), located in Norwalk, Connecticut, billed inpatient rehabilitation facility (IRF) claims that did not comply with Medicare documentation requirements. The Hospital improperly received $2.7 million in Medicare payments associated with the sampled claims. Based on our sample results, we estimate that Medicare overpaid the Hospital an additional $5.2 million for the 225 IRF claims that were not included in our sample.

For the 98 claims, the Hospital's medical records did not include sufficient documentation to support any of the following required elements: (1) documentation that a comprehensive preadmission screening occurred within the 48 hours immediately preceding the admission, (2) documentation that a rehabilitation physician performed a postadmission evaluation within the first 24 hours of the IRF admission, (3) documentation that a rehabilitation physician developed and documented an individualized overall plan of care within 4 days of the IRF admission, and (4) documentation that interdisciplinary team meetings met all Federal requirements. The Hospital's procedures did not ensure that IRF services were documented according to Medicare requirements.

We recommended that the Hospital (1) refund to the Medicare program $2.7 million for 98 IRF claims in our sample that did not comply with Medicare requirements; (2) work with CMS to resolve the 225 IRF claims that were not included in our sample, with potential overpayments estimated at $5.2 million; (3) identify IRF claims in subsequent years that did not meet Medicare documentation requirements and refund any associated overpayments; and (4) develop and implement procedures to ensure that it bills Medicare only for IRF services that comply with Medicare documentation requirements. The Hospital agreed with our fourth recommendation but disagreed with the rest of our recommendations.